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A nursing intervention is defined as a single nursing action – treatment, procedure or activity – designed to achieve an outcome to a diagnosis, nursing or medical, for which the nurse is accountable. [12] Patient services are usually initiated as medical orders by a referring physician and reviewed by the admitting nurse.
A hospital may also have a department of nursing, headed by a chief nursing officer or director of nursing. This department is responsible for the administration of professional nursing practice, research, and policy for the hospital. Many units have both a nursing and a medical director that serve as administrators for their respective ...
Nursing documentation mainly consists of a client's background information or nursing history referred as admission form, numerous assessment forms, nursing care plan and progress notes. These documents record the client's data captured at the relevant stages of the nursing process . [ 2 ]
An admission note is part of a medical record that documents the patient's status (including history and physical examination findings), reasons why the patient is being admitted for inpatient care to a hospital or other facility, and the initial instructions for that patient's care.
Progress Notes are the part of a medical record where healthcare professionals record details to document a patient's clinical status or achievements during the course of a hospitalization or over the course of outpatient care. [1] Reassessment data may be recorded in the Progress Notes, Master Treatment Plan (MTP) and/or MTP review. Progress ...
Sterile dental instruments from hospital central supply (barcoded label indicating sterilization date, expiry date and contents). The central sterile services department (CSSD), also called sterile processing department (SPD), sterile processing, central supply department (CSD), or central supply, is an integrated place in hospitals and other health care facilities that performs sterilization ...
Outpatient department of a hospital provides diagnosis and care for patients that do not need to stay overnight. [1] The departments are also sometimes called outpatient clinics, but are distinct from clinics independent of hospitals, almost all of which are designed mostly or exclusively for outpatient care and may be also be called outpatient clinics.
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